List I - Core Conditions

Question 1

What is acne?

Answer 1

• Acne vulgaris is a chronic inflammatory skin condition affecting mainly the face (99% of cases), back (60% of cases) and chest (15% of cases)

Question 2

What are the pathological features of acne vulagiris?

Answer 2

• Characterised by blockage and inflammation of the pilosebaceous unit (the hair follicle, hair shaft and sebaceous gland)
• Presents with lesions that can be non-inflammatory, inflammatory or a mixture of both
• Non-inflammed lesions are known as comedones which may be open (blackheads), closed (whiteheads) or microcomedones (clinically invisible)
• Inflammatory acne lesions include papules and pustules (5 mm or less in diameter) - in more severe disease these can develop into larger deeper pustules and nodules
• Most people with acne have a mixture of inflammatory and non-inflammatory lesions

Question 3

What is mild acne?

Answer 3

• Predominantly non-inflammed lesions (open and closed comedones) with few inflammatory lesions

Question 4

What is moderate acne?

Answer 4

• More widespread with an increased number of inflammatory papules and pustules

Question 5

What is severe acne?

Answer 5

• Widespread inflammatory papules, pustules and nodules or cysts, scarring may be present

Question 6

What is conglobate acne?

Answer 6

• A rare and severe form of acne found most often in men - presents with extensive inflammatory papules, suppurative nodules (which may coalesce to form sinuses) and cysts on the trunk and upper limbs

Question 7

What is acne fulminans?

Answer 7

• Sudden severe inflammatory reaction that precipitates deep ulcerations and erosions sometimes with systemic effects (fever and arthralgia)

Question 8

What is thought to cause acne?

Answer 8

• Not completely understood but thought thought to involve:
• Altered follicular keratinocyte proliferation leading to formation of follicular plugs (comedones)
• Androgen induced seborrhoea (increased sebum production) within the sebaceous follicles which usually occurs around puberty
• Proliferation of bacteria (such as propionibacterium acnes) within sebum in hair follicles
• Inflammation of the pilosebaceous unit

Other factors include:

• Genetic
• Racial and ethnic
• Diet

Question 9

How common is acne?

Answer 9

• Estimated 650 million worldwide
• Up to 95% of adolescents in Western industrialised countries are affected to some extent
• Distribution of people with acne:
• 85% aged 12-24 years
• 8% aged 25-34 years
• 3% aged 35-44 years
• More common in males during adolescence but in adulthood, incidence is higher in women

Question 10

What are the complications of acne vulagiris?

Answer 10

• Skin changes
• Scarring - acne may result in hypertrophic or atrophic scars which can be extensive
• Post inflammatory hyperpigmentation or depigmentation can occur
• Psychosocial effects
• Acne is associated with significant psychological problems including an increased risk of depression, suicide, anxiety, reduced attachment to friends and low self esteem

Question 11

What is the prognosis of acne vulgaris?

Answer 11

• Chronic disease that can persist for many years - tends to affect adolescents and usually resolves after the end of growth
• May persist into adulthood as a continuation of adolescence acne
• Predictive factors for persistence into adulthood for females is less clear

Question 12

What are the clinical features of acne vulgaris?

Answer 12

• Acne affects areas of the body with a high density of pilosebaceous glands such as the face, chest and back
• Clinical features vary widely depending on severity and the person affected
• Comedones must be present for a diagnosis of acne to be made if not present other diagnoses should be considered
• Suspect acne in a person presenting with:
• Non-inflammed lesions (comedones) which may be open (blackheads) or closed (whiteheads)
• Inflammatory lesions such as:
• Papules and pustules - superficial raised lesions (less than 5 mm in diameter)
• Nodules or cysts (larger than 5 mm in diameter) - deeper, palpable lesions which are often painful and may be fluctuant - very severe acne nodules may track together and form sinuses (acne conglobata)
• Scarring - atopic/ice pick or hypertrophic/keloid scars may be seen
• Pigmentation - post inflammatory depigmentation or hyperpigmentation may be present
• Seborrhoea - commonly present

Question 13

How should a history of a person with acne vulgaris be taken?

Answer 13

Ask about the following:

• Duration, type and distribution of lesions.
• Previous treatment (including over-the-counter medications) and response.
• Exacerbating factors such as flares with menstruation, contraceptives, cosmetics, face creams or hair pomades.
• Systemic features — some rare subtypes of acne (acne fulminans) can present with systemic features including fever, arthralgia, and myalgia.
• Psychosocial impact of acne — ask about psychological problems including anxiety and low mood.
• Family history including endocrine disorders, polycystic ovarian syndrome, acne and other skin conditions.
• Possible underlying causes:
• Drug history — some medications can cause or exacerbate acneform rashes including androgens, corticosteroids, isoniazid, ciclosporin and lithium.
• Hyperandrogenism — may present with irregular periods, androgenic alopecia or hirsutism in women

Question 14

What are the differential diagnoses of acne vulgaris?

Answer 14

• Rosacea
• Perioral dermatitis
• Folliculitis and boils
• Drug induced acne
• Dioxins (chloracne), corticosteroids, anti-epileptics (phenytoin and carbamazepine), lithium, isoniazid, vitamins B1, B6, and B12
• Keratosis pilaris

Question 15

What is the advice for initial conservative and management for the maintenance of healthy skin for people with acne vulgaris?

Answer 15

• Discuss treatment aims
• Advise to avoid over cleaning the skin (can cause dryness and irritation, acne is not caused by poor hygiene and twice daily washing with a gentle soap and fragrance-free cleanser is adequate
• If make up, cleansers and/or emollients are used, non-comedogenic preparations with a pH close to the skin are recommended
• Avoid picking and squeezing spots which may increase the risk of scarring
• Advise that treatments are effective but take time to work (usually up to 8 weeks) and may irritate the skin, especially at the start of treatment
• Maintain a healthy diet

Question 16

What is the management advice to people with mild to moderate acne vulgaris?

Answer 16

• Consider prescribing a single topical treatment such as:
• Topical retinoid (e.g. adapalene alone or in combination with benzyl peroxide NB retinoids are contraindicated in pregnancy and breast feeding
• Topical antibiotic (e.g. clindamycin 1%) - antibiotics should always be prescribed in combination with benzoyl peroxide to prevent development of bacterial resistance - topical benzoyl peroxide and erythromycin are usually considered to be safe in pregnancy
• Azelaic acid 20%
• Creams and lotions may be preferable for people with dry or sensitive skin and less greasy gels may be preferable for people with oily skin
• Concentration or application frequency of topical treatments may need to be reduced or lowered if skin irritation occurs

Question 17

What is the management advice to people with moderate acne vulgaris not responding to topical treatment?

Answer 17

• If response to topical preparations alone is inadequate consider adding an oral antibiotic, a tetracycline such as lymecycline or doxycycline (for a maximum of 3 months)
• Topical retinoid or benzoyl peroxide should always be prescribed with oral antibiotics to reduce the risk of resistance developing
• Macrolides such as erythromycin should generally be avoided due to high levels of P.acnes resistance but can be used if tetracyclines are contraindicated e.g. pregnancy
• Change to an alternative antibiotic if there is no improvement after 3 months
• Refer to dermatology if not responding to two different courses of antibiotics or if they are starting to scar

Question 18

What is the advice regarding combined oral contraceptives with acne vulgaris?

Answer 18

• COCP in combination with topical agents can be considered as an alternative to systemic antibiotics in women
• Oral progesterone only contraceptives or progestin implants with androgenic activity may exacerbate acne, 3rd and 4th generation COCP are preferred
• Co-cyprindiol (Dianette) or other ethinylestradiol/cyproterone acetate containing products may be considered in moderate to severe acne where other treatments have failed but require careful discussion of the risks and benefits with the patient
• Use should be discontinued 3 months after acne has been controlled and prescription guided by the UK Medical Eligibility Criteria

Question 19

When should a person with acne be referred to dermatology?

Answer 19

• Severe variant of acne such as acne conglobata or acne fulminans (immediate referral)
• Severe acne associated with visible scarring or are at risk of scarring or significant hyperpigmentation - primary care treatment should be initiated in the interim
• Multiple treatments in primary care have failed
• Significant psychological distress is associated with acne regardless of severity
• Diagnostic uncertainty

Question 20

When should follow up for acne treatment/management be arranged?

Answer 20

• Review each treatment step at 8-12 weeks
• If adequate response continue treatment for at least 12 weeks
• If acne has cleared or almost cleared - consider maintenance therapy with topical retinoids (first line) or azelaic acid
• If no response, check for adherence, adverse effects, progression to more severe acne, or use of comedogenic make up or face creams

Question 21

How should benzoyl peroxide be prescribed for acne vulgaris?

Answer 21

• For Child 12–17 years — apply to the skin 1–2 times a day, preferably after washing with soap and water and start treatment with lower-strength preparations.
• For Adult — apply to the skin 1–2 times a day, preferably after washing with soap and water, and start treatment with lower-strength preparations

Question 22

What are the cautions and contraindications for prescribing benzoyl peroxide?

Answer 22

• Hypersensitivity to the active substance or to any of the excipients.
• Avoid contact with broken skin, eyes, mouth and mucous membranes

Question 23

What are the adverse effects of benzoyl peroxide treatment?

Answer 23

• Skin irritation (dryness, discomfort, erythema, peeling and blistering) — reduce frequency or stop use until irritation settles then re-introduce at reduced concentration or frequency.
• Allergic contact dermatitis to benzoyl peroxide occurs in 1 in 500 people — consider if itching and swelling of the eyes occurs.
• Increased risk of sunburn — if sun exposure is unavoidable, an appropriate sunscreen or protective clothing should be used.
• May bleach fabrics and hair

Question 24

What is the indication for topical retinoids for the treatment of acne vulgaris?

Answer 24

• Adapalene and tretinoin are the topical retinoids licenced for use in children over the age of 12 and adults in the UK.
• Topical isotretinoin is licenced for use in adults only
• If peeling due to use of other irritant acne treatments is present, allow to subside before starting a topical retinoid — discontinue use if severe irritation occurs.
• Topical retinoids should be used sparingly to cover the whole affected area and not just on visible spots — if the person has sensitive skin, initiate therapy at a lower frequency (for example three times per week) and increase to daily use as tolerated.
• Concomitant use of a noncomedogenic moisturizer and sunscreen may also help tolerability

Question 25

What are the contraindications to the use of topical retinoids for the treatment of mild to moderate acne vulgaris?

Answer 25

* Hypersensitivity to the active substance or to any of the excipients. * Avoid in pregnancy and breastfeeding — women of child-bearing age must use effective contraception. * Avoid in people with severe acne, perioral dermatitis, rosacea or a personal or family history of non-melanoma skin cancer. * Avoid accumulation in angles of the nose and contact with eyes, nostrils, mouth and mucous membranes, eczematous, broken or sunburned skin. * Avoid exposure to excess UV light (including sunlight and solariums) — if sun exposure is unavoidable, an appropriate sunscreen or protective clothing should be used

Question 26

What are the adverse affects of using topical retinoids for the acne?

Answer 26

* Skin irritation including discomfort, blistering of skin, burning, crusting, dryness, peeling, erythema, oedema, pruritus, stinging, contact dermatitis and temporary changes of skin pigmentation. * Eye irritation. * Increased sensitivity to UV light — if sun exposure is unavoidable, an appropriate sunscreen or protective clothing should be used

Question 27

Which topical antibiotics can be prescribed for acne vulgaris?

Answer 27

* Clindamycin * Erythromycin Should be prescribed in combination with benzoyl peroxide - monotherapy not recommended

Question 28

How should azelaic acid be prescribed for acne vulgaris?

Answer 28

* For Child 12–17 years — apply twice daily. In people with sensitive skin, apply once daily for 1 week, then apply twice daily. * For Adult — apply twice daily. In people with sensitive skin, apply once daily for 1 week, then apply twice daily. * If skin irritation occurs reduce the amount used or frequency of application to once a day until the irritation ceases — temporarily interrupt treatment for a few days if required

Question 29

When should oral antibiotics be prescribed for acne vulgaris?

Answer 29

* If acne fails to respond adequately to topical preparations alone an oral antibiotic such as lymecycline or doxycycline (for a maximum of 3 months) can be added

Question 30

What is acne rosacea?

Answer 30

* Chronic inflammatory skin condition predominantly affecting the convexities of the centrofacial region (cheeks, chin, nose, and central part of the forehead)

Question 31

What are the clinical features of acne rosacea?

Answer 31

* Typically affects nose, cheeks, and forehead * Flushing is often first symptom * Telangiectasia are common * Later develops into persistent erythema with papules and pustules * Rhinophyma * Ocular involvement - blepharitis * Sunlight may exacerbate symptoms

Question 32

What are the management options of acne rosacea?

Answer 32

* Topical metronidazole may be used for mild symptoms i.e. limited number of papules and pustules, no plaques * Topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia * More severe disease is treated with systemic antibiotics e.g. oxytetracycline * Recommended daily application of a high factor sunscreen * Camoflage creams may help conceal redness * Laser therapy may be appropriate for patients with prominent telangiectasia * Patients with a rhinophyma should be referred to dermatology

Question 33

What is eczema?

Answer 33

* Atopic eczema (also known as atopic dermatitis) is a chronic, itchy, inflammatory skin condition that affects people of all ages, although it presents most frequently in childhood * Typically an episodic disease of flares and remissions, in severe cases disease activity may be continuous

Question 34

What is the cause of eczema?

Answer 34

* Complex condition involving genetic, immunological and environmental factors, leading to a dysfunctional skin barrier and immune system dysregulation * Recent evidence suggests that mutatitions in the filaggrin gene is a likely cause for almost 50% of cases of atopic eczema - filaggrin gene is essential for the conversion of keratinocytes to the protein/lipid squames that make up the outermost barrier layer of the skin (stratum corneum) - defect in filaggrin causes skin barrier dysfunction * Primary function of the skin barrier is to restrict water loss and to prevent entry of irritants, allergens, and skin pathogens

Question 35

What is the pathogenesis of eczema as a result of filaggrin gene dysfunction?

Answer 35

* Leads to water loss from the skin, leading to dryness and itching * Makes the skin susceptible to allergens, leading to hyperreactive and induction of immunoglobulin E (IgE) autoantibodies * Predisposes the skin to colonisation or infection by microbes, such as staphylococcus aureus

Question 36

What are the factors thought to trigger atopic eczema?

Answer 36

* Soap and detergent, animal dander, house-dust mites, extreme temperatures, rough clotting, pollen, certain foods and stress

Question 37

How common is eczema?

Answer 37

* Common and prevalence is increasing * Affects 10-30% of children * 2-10% of adults

Question 38

What are the complications of eczema?

Answer 38

* Infection - Bacterial infection with stapylococcus aureus may present as typical impetigo or as worsening of eczema (with increased redness, oozing and crusting of the skin) - Herpes simplex infection indicated by punched out erosions may occur - Disseminated herpes simplex virus infection (eczema herpeticum) presents with widespread lesions that may coalesce into large, denuded, bleeding areas that can extend over the entire body, occasionally complicated by secondary infection with staphylococcal or streptococcal species - Fever, lymphadenopathy and malaise are common with eczema herpetiform - medical emergency in children under the age of 2 years * Psychosocial problems - Distress and depression - Preschool children have higher rates of behaviour problems and problems with poor self image and self confidence that can impair social development - Sleep disturbance is a major problem in atopic eczema and their families

Question 39

What is the prognosis of patients with eczema?

Answer 39

* Atopic eczema typically is episodic with flares of disease (two or three times per month) and remissions * Atopic eczema has a tendency to gradual improvement in adult life * Condition is expected to clear in about 65% of children by the time they are 7 years of age an in about 74% of children by the age of 16 years * Many children with atopic eczema will go on to develop asthma (30-50%) and/or hay fever (30-80%)

Question 40

What questions should be asked in taking a history of eczema?

Answer 40

* Presence of itching - if no itch then atopic eczema is unlikely * Pattern, time of onset and natural history of the rash - atopic eczema usually starts in infancy and is episodic in nature * Family or personal history of atopy - allergic rhinitis and asthma are associated with atopic eczema * Treatments tried and response * Possible triggers (irritant or allergic)

Question 41

What should you look for on examination of a person with suspected eczema?

Answer 41

* In adults - generalised dryness and itching particularly with exposure to irritants - on the hands may be the primary manifestation * in children and adults with long standing disease - eczema is often located on the flexure of the limbs * In infants - eczema primarily involves the face, the scalp, and the extensor surfaces of the limbs - nappy area spared * Acute eczema - varies in appearance from poorly demarcated redness to fluid in the skin (vesicles), scaling or crusting of the skin * Chronic eczema - characterised by thickened (lichenified) skin resulting from repeated scratching * If eczema is weeping, crusted or there are pustules with fever or malaise secondary bacterial infection should be considered

Question 42

What are the NICE criteria for making a diagnosis of eczema?

Answer 42

* An itchy skin condition (or parental report of scratching) plus 3 or more of the following: - Visible flexural eczema involving the skin creases, such as the bends of the elbows or behind the knees (or visible eczema on the cheeks and/or extensor areas in children aged 18 months or younger) - Personal history of flexural eczema (or eczema on the cheeks and/or extensor areas in children aged 18 months or younger) - Personal history of dry skin in the last 12 months - Personal history of asthma or allergic rhinitis (or history of atopic disease in a first degree relative of a child aged under 4 years - Onset of signs and symptoms before the age of 2 years (this criterion should not be used in children younger than 4 years of age) NB these criteria apply to all ages, social classes, and ethnic groups. However, in children of Asian, black Caribbean, and black African ethnic groups, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid or follicular patterns may be more common.

Question 43

What are the potential trigger factors to ask about in a person suspected of having eczema?

Answer 43

* Irritant allergens * Irritant clothing * Skin infections * Contact allergens * Inhaled allergens * Hormonal triggers * Climate * Concurrent illness and disruption to family life * Dietary factors

Question 44

What are the differential diagnoses for eczema?

Answer 44

* Psoriasis * Allergic contact dermatitis * Seborrhoeic dermatitis * Fungal infection * Scabies or other infestations

Question 45

How is treatment of eczema guided?

Answer 45

* At each consultation assess the severity of the eczema in order to determine the most appropriate treatment * At each consultation assess the psychological impact of atopic eczema

Question 46

How is the severity of the eczema determined?

Answer 46

* Examine all areas of affected skin and ask about itching * Clear - normal skin, no evidence of active eczema * Mild - areas of dry skin and infrequent itching (with or without small areas of redness) * Moderate - areas of dry skin, frequent itching and redness (with or without excoriation and localised skin thickening) * Severe - widespread areas of dry skin, incessant itching and redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation * Infected - eczema is weeping, crusted or there are pustules with fever or malaise

Question 47

What can be used to assess the patients severity of eczema?

Answer 47

* Validated tools such as a visual analogue scale (0-10) of the person's assessment of severity, itch, and sleep loss over the last 3 days and nights or the Patient-Oriented Eczema Measure

Question 48

How is the psychological impact of atopic eczema measured?

Answer 48

* Ask about the effect of eczema on daily activities (school, work and social life) , sleep and mood * Categorised the impact on quality of life and psychosocial well being as: None - no impact Mild - little impact on everyday activities, sleep and psychosocial well being Moderate - moderate impact on everyday activities and psychosocial well being and frequently disturbed sleep Severe - severe limitation of everyday activities and psychosocial functioning and loss of sleep every night

Question 49

What can be used to assess the patients psychological impact of eczema?

Answer 49

* Consider using questionnaires to give an objective measure of quality of life * Children's / Adult's Dermatology Life Quality Index

Question 50

What is the management for mild eczema?

Answer 50

* Prescribe generous amounts of emollients, and advise frequent and liberal use. * Consider prescribing a mild topical corticosteroid (such as hydrocortisone 1%) for areas of red skin. Treatment should be continued for 48 hours after the flare has been controlled

Question 51

What is the management for moderate eczema?

Answer 51

* Prescribe a generous amount of emollients, and advise frequent and liberal use (more than usual) * If the skin is inflamed, prescribe a moderately potent topical corticosteroid (for example betamethasone valerate 0.025% or clobetasone butyrate 0.05%) to be used on inflamed areas. Treatment should be continued for 48 hours after the flare has been controlled * For delicate areas of skin (such as the face and flexures), consider starting with a mild potency topical corticosteroid (such as hydrocortisone 1%) and increase to a moderate potency corticosteroid only if necessary. Aim for a maximum of 5 days' use * Consider prescribing a maintenance regimen of topical corticosteroids to control areas of skin prone to frequent flares (not recommended for the face, genitals, or axillae)

Question 52

What is the management for severe eczema?

Answer 52

* Prescribe a generous amount of emollients and advise frequent and liberal use (more than usual) * If the skin is inflamed, prescribe a potent topical corticosteroid (for example betamethasone valerate 0.1%) to be used on inflamed areas * For delicate areas of skin such as the face and flexures, use a moderate potency corticosteroid (such as betamethasone valerate 0.025% or clobetasone butyrate 0.05%). Aim for a maximum of 5 days' use * Consider prescribing a maintenance regimen of topical corticosteroids to control areas of skin prone to frequent flares (not recommended for the face, genitals, or axillae)

Question 53

How should infected eczema be managed?

Answer 53

* Flucloxacillin is the first-line choice. * Prescribe erythromycin if the person has an allergy to penicillin or if there is known resistance to flucloxacillin. If the person has previously been unable to tolerate erythromycin because of nausea or cramps, consider prescribing clarithromycin

Question 54

What is the principle regarding topical steroid treatment for eczema?

Answer 54

* Use the weakest steroid cream which controls the patients symptoms

Question 55

What is a mild potency topical steroid?

Answer 55

* Hydrocortisone | 0. 5-2.5%

Question 56

What is a moderate potency topical steroid?

Answer 56

* Betamethasone valerate 0.025% (Betnovate RD) | * Clobetasone butyrate 0.05% (Eumovate)

Question 57

What is a potent topical steroid?

Answer 57

* Fluticasone propionate 0.05% (Cutivate) | * Betamethasone valerate 0.1% (Betnovate)

Question 58

What is a very potent topical steroid?

Answer 58

* Clobetasol propionate 0.05% (Dermovate)

Question 59

What is the guidance to patients in terms of sufficient amounts of emolient/topical steroids to use?

Answer 59

* Finger tip rule | - 1 finger tip unit (FTU) = 0.5 g sufficient to treat a skin area about twice that of the flat of an adult hand

Question 60

What finger tip dose of topical steroid for an adult is required to cover the hand and fingers (front and back)?

Answer 60

* 1.0

Question 61

What finger tip dose of topical steroid for an adult is required to cover a foot (all over) ?

Answer 61

* 2.0

Question 62

What finger tip dose of topical steroid for an adult is required to cover the front of chest and abdomen?

Answer 62

* 7.0

Question 63

What finger tip dose of topical steroid for an adult is required to cover the back and buttocks?

Answer 63

* 7.0

Question 64

What finger tip dose of topical steroid for an adult is required to cover the face and neck?

Answer 64

* 2.5

Question 65

What finger tip dose of topical steroid for an adult is required to cover an entire arm and hand?

Answer 65

* 4.0

Question 66

What finger tip dose of topical steroid for an adult is required to cover an entire leg and foot?

Answer 66

* 8.0

Question 67

What is psoriasis?

Answer 67

* Systemic immune mediated, inflammatory skin disease which typically has a chronic relapsing remitting course and may have nail and joint involvement * Skin lesions of psoriasis are characterised by: - Epidermal hyperproliferation - cells are multiplying too quickly - Abnormal keratinocyte differentiation - cells not maturing normally - Lymphocyte inflammatory infiltrate - presence of cells which cause inflammation

Question 68

What are the different forms of psoriasis that exist?

Answer 68

* Chronic plaque psoriasis including scalp psoriasis and facial psoriasis - affecting 80-90% of people with psoriasis * Localised pustular psoriasis of the palms and soles - second most common form * Flexural psoriasis - known as inverse psoriasis may affect 3-7% of people with psoriasis * Guttate psoriasis - accounts for 2% of psoriasis cases, also known as droplet psoriasis and can affect any site of the body * Erythrodermic psoriasis - rare * Generalised pustular psoriasis - rare * Nail psoriasis - affects 50% of all people with psoriasis at diagnosis with a lifetime incidence of 80-90%, it is more common in people with psoriatic arthritis (up to 90% of people have nail involvement) Up to 10% of people with psoriasis will present with only nail manifestations

Question 69

How common is psoriasis?

Answer 69

* 1-3% of the worlds population has psoriasis * 1.3-2.2% of the UK population is estimated to have psoriasis * Onset may occur at any age but there are two peaks in incidence between 20-30 years and 50-60 years * Guttate psoriasis is more common in people under the age of 30 years

Question 70

What factors are thought to trigger psoriasis?

Answer 70

* Streptococcal infection - strongly associated with guttate psoriasis especially with URTI * Drugs - lithium, antimalarial drugs such as chloroquine, beta blockers and NSAIDs and ACEi, trazadone, terfenadine and antibiotics such as tetracyline and penicillin * UV light exposure * Trauma * Hormonal changes * HIV infection and AIDS * Psychological stress * Smoking * Alcohol

Question 71

What other conditions are associated with psoriasis?

Answer 71

* Psoriatic arthritis - 30% of people with psoriasis, skin psoriasis usually develops before joint involvement in the majority of cases with typical time lag of 5-10 years * Metabolic syndrome including obesity, hyperlipidaemia, hypertension, T2 DBM, and non-alcoholic fatty liver disease * Ischaemic heart disease * IBD * Anxiety and depression * Venous thromboembolism * Non-melanoma skin cancer

Question 72

What are the possible complications of psoriasis?

Answer 72

* Psychosocial effects - Anxiety and depression - Relationship difficulties, negative body image and low self esteem, feelings of shame, guilt, embarrassment and fear of being considered dirty or infectious * Physical effects - Erythrodermic psoriasis may be life threatening due to its impact on temperature regulation, haemodynamics, intestinal absorption and protein and water metabolism - any form of psoriasis may become erythrodermic - Complications include - Heart failure - Malabsorption - Hypothermia - Dehydration - Mild anaemia * Pregnancy - Some studies show an increased risk of women with severe psoriasis delivering low birth weight infants

Question 73

What is the prognosis for people with psoriasis?

Answer 73

* Usually a chronic condition, spontaneous remission can occur in up to 25% of people with psoriasis and this may last for months * Guttate psoriasis is usually self limiting and typically resolves within 3-4 months of onset - about 1/3 of people with guttate psoriasis develop classic plaque disease * Early onset disease is associated with being female and having an affected first degree relative * Disease onset at an earlier age may predict more extensive, sever and unstable disease

Question 74

What questions should be asked when taking a history from a person with psoriasis?

Answer 74

Ask about: * Sites and extent of involvement to help classify the type of psoriasis * Symptoms of skin involvement, such as itch, irritation, burning, pain, bleeding and scaling * Symptoms of systemic illness, such as fever malaise and weight loss, especially if medical emergencies such as generalised pustular psoriasis or erythrodermic psoriasis are suspected * Known trigger factors or any relationship to areas of trauma suggesting the Koebner phenomenon * Articular symptoms of unexplained joint stiffness, pain or swelling or nail changes * Consider using the Psoriasis Epidiemiology Screening Tool (PEST) - if a person scores 3 or more out of 5, consider arranging a referral to a rheumatologist NB PEST does not detect axial arthritis or inflammatory back pain * Associated conditions IBD or obesity * Treatments OTC * Persons perception of severity of psoriasis - consider the 7 point Patients Global Assessment (PGA) score with points indicating increasing severity: ranging from clear (scores 0), nearly clear, mild, moderate severe or very severe (6) * Consider the Dermatology Life Quality Index tool to assess the impact of psoriasis - be aware that degree of impact may not correlate with objective measures of disease extent or severity * Assess the persons CV risk

Question 75

What should be examined on a person with psoriasis?

Answer 75

* Signs of systemic illness such as fever or hypothermia, weight loss, dehydration, tachycardia, hypotension * Assess skin lesions over the whole body where possible to classify the type of psoriasis: - Distribution - Size and shape of lesions - Number of lesions - Severity of lesions - Surface features - Colour - Involvement of other areas * Assessment can be documented using the proportion of the TBSA affected using the 'Rule of Nines' (traditionally used for burns assessment (Lund and Browder chart) * Arm - 9% * Head - 9% * Neck - 1% * Leg - 18% * Anterior trunk - 18% * Posterior trunk - 18%

Question 76

How should psoriasis be classified?

Answer 76

* According to clinical features and site of involvement it can be: - Pustular psoriasis - Erythrodermic psoriasis - Chronic plaque psoriasis - Scalp psoriasis - Facial psoriasis - Flexural psoriasis - Guttate psoriasis - Nail psoriasis

Question 77

What are the clinical features of pustular psoriasis?

Answer 77

* Generalized pustular psoriasis (a potentially life-threatening medical emergency) * Rapidly developing widespread erythema, followed by the eruption of white, sterile non-follicular pustules which coalesce to form large lakes of pus. * Lesions associated with systemic illness, such as fever, malaise, tachycardia, weight loss, and arthralgia. * Usually presents in people with existing or previous chronic plaque psoriasis, but can also occur in people without a history of psoriasis * Localized (palmoplantar) pustular psoriasis * Lesions on the palms and soles, such as yellow-brown pustules within established psoriasis plaques, or redness, scaling, and pustules at the tips of the fingers and toes

Question 78

What are the clinical features of erythrodermic psoriasis?

Answer 78

* Potentially life threatening medical emergency * Diffuse, widespread severe psoriasis that affects more than 90% of the body surface area * Can develop gradually from chronic plaque psoriasis or appear abruptly even in people with mild psoriasis * Can be precipitated bay various factors such as systemic infection, irritants such as coal tar or ciclosporin, phototherapy or sudden withdrawal of corticosteroids * Lesions may feel warm and may be associated with systemic illness such as fever, malaise, tachycardia, lymphadenopathy and peripheral oedema

Question 79

What are the clinical features of chronic plaque psoriasis?

Answer 79

* Monomorphic, erythematous plaques covered by adherent silvery-white scale, usually on the scalp, behind the ears, trunk, buttocks, periumbilical area, and extensor surfaces (such as forearms, shins, elbows, and knees) * Lesions which are typically distributed symmetrically and can coalesce to form larger lesions * On white skin, the plaques are pink or red; in deeply pigmented skin, plaques usually have a grey colour and may cause marked post-inflammatory hyperpigmentation. * Most lesions are 1 cm to several centimetres in diameter, with an oval or irregular shape. * There is usually a clear delineation between normal and affected skin. * Scale is usually present — it is usually silver-white in colour, but less commonly can be a waxy yellow or orange-brown. The thickness of the scale varies, but it can be very thick. If the scale is gently removed, a glossy red membrane with pinpoint bleeding points (Auspitz's sign) is revealed. * Occasionally, a halo-like effect is seen around a plaque, due to vasoconstriction (Woronoff's ring). * Fissures may form if the plaque is over a joint line or on the palm or sole

Question 80

What are the clinical features of scalp psoriasis?

Answer 80

* Scalp psoriasis affects 75-90% of people with psoriasis * Typically presents as chronic plaque psoriasis affecting the scalp area * Plaques may be very thick, particularly in the occipital region * May be associated with areas of non-scarring alopecia in some people particularly in there is" - Thick, adherent scale extending up the hair shaft (pityriassis amiantacea) - Erythrdermic psoriasis - can cause severe alopecia - Repeated scratching of the scalp due to itch

Question 81

What are the clinical features of facial psoriasis?

Answer 81

* Typically presents as: * Well demarcated plaques on the face, similar to those of chronic plaque psoriasis * Lesions which may affect the hairline * Possible mild scaling around the eyebrows and nasolabial folds, which may be due to co-existent seborrhoeic dermatitis (so called sebo-psoriasis)

Question 82

What are the clinical features of flexural psoriasis?

Answer 82

* Typically presents as: * Itchy psoriasis lesions affecting areas such as the groin, genital area, axillae, inframammary folds, abdominal folds, sacral and gluteal cleft * The elderly, immobile, and people who are overweight or obese are at increased risk of being affected * Lesions of chronic plaque psoriasis which are well-defined, but there may be little or no scaling, due to friction and occlusion at these sites. * Lesions are often red and glazed in appearance, and there may be a fissure in the skin crease

Question 83

What are the clinical features of guttate psoriasis?

Answer 83

* Typically presents as: * Small, scattered, round or oval (2 mm to 1 cm diameter) scaly papules which may be pink or red * Multiple lesions which may occur all over the body over a period of 1–7 days, particularly on the trunk and proximal limbs. Lesions may occur on the face, ears, and scalp, but rarely affect the soles of the feet * A first presentation of psoriasis (classically after acute streptococcal upper respiratory tract infection), or as an acute exacerbation of plaque psoriasis

Question 84

What are the clinical features of nail psoriasis?

Answer 84

* More commonly affects the finger nails than toenails (50% and 35% respectively) and may affect all parts of the nail and the surrounding structures * Nail changes can occur with any type of psoriasis and are particularly common in people with psoriatic arthritis (up to 90%) * Nail pitting (depressions in the nail plate) is the most common finding. * Discolouration (for example the 'oil drop sign') — orange-yellow discolouration of the nail bed. * Subungual hyperkeratosis — hyperproliferation of the nail bed, with accumulation of keratinocytes under the nail. * Onycholysis — detachment of the nail from the nail bed, which may allow bacteria and fungi to enter and cause infection. * Complete nail dystrophy

Question 85

What are the differential diagnoses of psoriasis?

Answer 85

* Seborrhoeic dermatitis * Fungal skin infection * Fungal nail infection * Candidal intertrigo * Norwegian scabies * Secondary syphillis * Bacterial infection * Eczema * Lichen planus * Lichen simplex chronicus * Discoid lupus erythematosus * Cutaneous T-cell lymphoma

Question 86

What are the differential diagnoses for guttate psoriasis?

Answer 86

* Viral exanthems * Pityriasis rosea * Drug eruptions

Question 87

What are the differential diagnoses for generalised pustular psoriasis?

Answer 87

* Pyogenic infections * Vasculitis * Drug eruptions

Question 88

How should a person with suspected pustular or erythrodermic psoriasis be managed?

Answer 88

* Medical emergency - arrange for immediate same day specialist dermatology assessment and ongoing management

Question 89

What is the management of chronic plaque psoriasis?

Answer 89

* Regular emollients may help to reduce scale loss and reduce pruritis * First line - NICE recommend a potent corticosteroid applied once daily plus vitamin D analogue applied once daily (morning and evening) for up to 4 weeks as initial treatment * Second line - if there is no improvement after 8 weeks then offer a vitamin D analogue twice daily * Third line - if there is no improvement after 8-12 weeks then offer either a potent corticosteroid applied twice daily for up to 4 weeks or a coal tar preparation applied once or twice daily * Short acting dithranol can also be used

Question 90

What are the NICE recommendations regarding the use of topical steroids in psoriasis?

Answer 90

* Topical steroids can lead to skin atrophy, striae and rebound symptoms * Systemic side effects may be seen when potent corticosteroids are used on large areas e.g. >10% of the body surface area * NICE recommend aiming for a 4 week break before starting another course of topical corticosteroids * NICE also recommend using potent corticosteroids for no longer than 8 weeks at a time and very potent corticosteroids for no longer than 4 weeks at a time

Question 91

What is the role of vitamin D analogues for the treatment of psoriasis?

Answer 91

* Examples include calcipotriol (Dovonex), calcitrol and tacalcitol * Work by reducing cell division and differentiation * Adverse effects are uncommon * Can be used long term * Do not smell or stain (unlike coal tar) * Tend to reduce the scale and thickness of plaques but not the erythema * Should be avoided in pregnancy * Maximum weekly amount for adults is 100g

Question 92

How should topical steroids be used for the treatment of psoriasis?

Answer 92

* Topical steroids are commonly used in flexural psoriasis and there is also a role for mild steroids in facial psoriasis * If ineffective, vitamin D analogues or tacrolimus ointment should be used second line * Patients should have 4 week break between course of topical steroids * Very potent steroids should not be used for longer than 4 weeks at a time * Potent steroids can be used for up to 8 weeks at a time * Scalp, face and flexures are particularly prone to steroid atrophy so topical steroids should not be used for more than 1-2 weeks/month

Question 93

What is the NICE guidance regarding the use of steroids for scalp psoriasis?

Answer 93

* NICE recommend the use of potent topical corticosteroids used once daily for 4 weeks * If no improvement after 4 weeks then either use a different formulation of the potent corticosteroid (for example, shampoo or mousse) and/or a topical agent to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid

Question 94

What is the NICE guidance regarding the use of topical corticosteroids for the face, flexutal and genital psoriasis?

Answer 94

* NICE recommend offering a mild or moderate potency corticosteroid applied once or twice daily for a maximum of 2 weeks

Question 95

What are the secondary care options for the management of psoriasis?

Answer 95

* Phototherapy - Narrow band UV B light is the treatment of choice - if possible given 3 times per week - Photochemotherapy is also used - psoralen + UV A light - Adverse effects are skin ageing, squamous cell cancer (not melanoma) * Systemic therapy - Oral methotrexate is used first line - particularly useful if there is associated joint disease - Ciclosporin - Systemic retinoids - Biological agents - infliximab, etanercept and adalimumab

Question 96

What is the mechanism of action of coal tar for the treatment of psoriasis?

Answer 96

* Inhibits DNA synthesis

Question 97

What is the mechanism of action of calcipotriol for the treatment of psoriasis?

Answer 97

* Vitamin D analogue which reduce epidermal proliferation and restores a normal horny layer

Question 98

What is the mechanism of action of dithranol for the treatment of psoriasis?

Answer 98

* Inhibits DNA synethesis - wash off after 30 minutes | * Side effects - burning, staining

Question 99

What is the Koebner phenomenon?

Answer 99

* Describes skin lesions which appear at the site of injury, it is seen in: - Psoriasis - Vitiligo - Warts - Lichen planus - Lichen sclerosis - Molluscum contagiosum

Question 100

What is a wart?

Answer 100

* Cutaneous warts are small, rough growths that are caused by infection of keratinocytes with HPV * Can appear anywhere on the skin but are commonly seen on the hands and feet

Question 101

What is a verruca?

Answer 101

* Also known as a plantar wart is a wart on the sole of the foot

Question 102

How are cutaneous warts classified?

Answer 102

* Common wart (verruca vulgaris) * Flat wart or plane wart (verruca plana) * Plantar wart - wart on the sole of the foot (verruca plantaris) * Periungual wart - wart around the fingernails or toenails

Question 103

How common are warts?

Answer 103

* Cutaneous warts are common and can occur at any age, they are rare in infants and very young children * Estimated 2-30% of school age children and young adults have warts

Question 104

How are warts transmitted?

Answer 104

* Usually spread from skin to skin contact or indirectly via contact with contaminated floors or surfaces (swimming pools or shower room floors) * Risk of developing cutaneous warts is increased if the skin is damaged and/or macerated * Wart is scratched or knocked and bleeds * Occupation involves regular handling of meat or fish associated with greater risk * Person is immunosuppressed * Incubation period of warts is thought to range from a few weeks to more than a year

Question 105

What is the prognosis of warts?

Answer 105

* Warts may clear spontaneously at any time or persist for years * Prognosis varies from person to person and is usually more rapid in children * 60-70% will resolve spontaneously within 2 years and 95% within 4 years * Clearance time may sometimes be prolonged in adults (for example 5-10 years)

Question 106

What are the complications of warts?

Answer 106

* Spread caused by picking at the wart * Local infection * Changes in skin pigmentation and scarring following destructive treatments * Malignant changes - thought to be rare but have been reported in immunosuppressed people, lesions initially appeared as warts and later transform into squamous cell carcinoma

Question 107

How are warts diagnosed?

Answer 107

* From their typical appearance * Common warts - Firm, raised papules with a rough surface that resembles a cauliflower (common on knuckles, knees, and fingers) usually asymptomatic but may be tender * Periungual warts - Are common warts around nails that can be painful and disturb nail growth - nail biting is a risk factor * Plan warts - Usually round, flat topped and skin coloured or greyish yellow (common on the backs of hands) * Filiform warts - Finger like appearance and may have a stalk (more common on the face and neck) * Palmar and plantar warts - Grow on the palms and the soles of the feet (verrucae) - Often have central dark dots (thrombosed capillaries) and may be painful * Maosaic warts - Occur when palmar or plantar warts coalesce into larger plaques on the hands and feet

Question 108

What are the differential diagnoses of warts?

Answer 108

* Can include hyperkeratotic lesions of the hand or feet for example: - Actinic keratosis - Bowen's disease - Seborrheic keratosis - Knuckle pads - Squamous cell carcinoma - Focal palmoplantar keratoderma - Lichen planus - Angiokeratoma - Corns or calluses - Malignant melanoma

Question 109

Should warts and verrucae be treated?

Answer 109

* For most there is a strong case for not treating warts or verrucae * Most self resolve within months, at most in 2 years in some adults in 5-10 years * Treatment can be prolonged and can have adverse side effects - Cryotherapy requires several treatments and can be painful, cause blistering, infection, scarring and depigmentation - Topical salicylic acid may require administration for up to 12 weeks and can cause local skin irritation Consider treatment if: - Wart is painful e.g. soles of feet or near the nails - Wart is cosmetically unsightly e.g. on the hands or face - Person requires treatment and the wart is persisting

Question 110

What treatments for warts can be done in primary care?

Answer 110

* Non-facial warts (adults and children) - Topical salicylic acid (15-50%) applied daily for up to 12 weeks - Cryotherapy with liquid nitrogen (usually carried out every 2 weeks until the wart is gone, up to a maximum of 6 treatments) - only suitable for some older children able to tolerate the treatment - Combination therapy of the above 2 - Shorter cryotherapy freeze (5-10 seconds) or a weaker strength topical salicylic acid preparation (17% or less) is recommended for plane warts on the back of the hands to reduce scarring - For younger children offer treatment with topical salicylic acid applied daily for up to 12 weeks

Question 111

When should a person with warts or verrucae be referred?

Answer 111

* Consider referral to a dermatologist for warts if: - Facial wart - Diagnosis uncertain - Immunocompromised - Extensive areas of skin affected e.g. mosaic warts of the hands and feet - Person is bothered by persistent warts that are unresponsive to both topical salicylic acid and cryotherapy if indicated

Question 112

What are the treatment options for warts in secondary care?

Answer 112

* Physical ablation such as surgery, laser treatment and photodynamic therapy * Antimitotic treatment such as podophyllotoxin, topical or oral retinoids or intralesional bleomycin * Immunomodulatory treatments such as topical sensitisers (squaric acid dibutylester), topical imiquimod 5% or intralesional interferon * Virucidal treatment such as formaldehyde and glutaraldehyde * Cantharidin (potent blistering agent from beetles)

Question 113

What advice should be given to someone with warts?

Answer 113

* Although they can be unsightly they do not usually cause symptoms and resolve without treatment * Warts are contagious but risk of transmission is thought to be low * To reduce transmission risk: - Cover with a waterproof plaster when swimming - Wear flipflops - Avoid sharing shoes, socks, or towels * To limit personal spread - Avoid scratching - Avoid biting nails - Keep feet dry and change socks daily * Children do not need to be excluded from activities such as sports and swimming * Provide patient information such as: - Plantar warts from the BAD - Warts and verrucas from the NHS - Cryotherapy from the BAD

Question 114

What are the types of salicylic acid topical available?

Answer 114

* Duofilm * Bazuka extra strength * Occlusal * Salactol * Scholl Verruca Removal System

Question 115

Who should not receive topical salicylic acid?

Answer 115

Topical salicylic acid should not be used on: - The face. - Intertriginous or anogenital regions. - Moles or birthmarks. - Mucous membranes. - Warts with hair growing out of them, red edges, or an unusual colour. - Open wounds, irritated or reddened skin, or any area that is infected. - Areas of poor healing, such as neuropathic feet, or in those with impaired blood circulation. - Children under the age of 2 years. - Children or teenagers during or immediately after chickenpox, influenza, or other viral infections owing to a theoretical risk of Reye's syndrome. - Avoid applying to normal skin. - For some products the manufacturers recommend avoidance of use in pregnancy and lactation

Question 116

What are the clinical features of a basal cell carcinoma?

Answer 116

* Ulcer with a raised rolled edge * Prominent fine blood vessels around a lesion or a nodule on the skin (particularly pearly or waxy nodules) * Often it is possible to diagnose a typical basal cell carcinoma visually but confirmation of the diagnosis is generally made by excision biopsy

Question 117

How common is a basal cell carcinoma?

Answer 117

* Approximately 75,000 basal cell carcinomas of the skin are diagnosed each year. * A full time GP likely to diagnose at least one person with basal cell carcinoma per year

Question 118

What is the prognosis of a person with BCC?

Answer 118

* Death from basal cell carcinoma is exceptionally rare. | * The main advantage from early diagnosis is less extensive treatment

Question 119

How should a person with features suggestive of BCC be managed?

Answer 119

* Consider routine referral * Only consider a suspected cancer pathway referral (for an appointment within 2 weeks) if there is particular concern that delay may have a significant impact because of factors such as lesion site or size

Question 120

What are the management options for a BCC?

Answer 120

* Surgical removal * Curettage * Cryotherapy * Topical cream: imiquimod, fluorouracil * Radiotherapy

Question 121

What are the clinical features of a squamous cell carcinoma?

Answer 121

* Usually presents as an indurated nodular keratinising or crusting tumour that may ulcerate or it may present as an ulcer without evidence of keratinisation * Squamous cell carcinoma usually appears on the head and neck * It is often possible to diagnose a typical sqaumous cell carcinoma visually but confirmation of the diagnosis is generally made by excision biopsy

Question 122

How common is squamous cell carcinoma?

Answer 122

* Approximately 25,000 squamous cell carcinomas of the skin are diagnosed each year. * A full time GP likely to diagnose at least one person with squamous cell carcinoma every 1-2 years

Question 123

What is the prognosis of a person with SCC?

Answer 123

* Death from squamous cell carcinoma is rare. | * The main advantage from early diagnosis is less extensive treatment.

Question 124

How should a person with features suggestive of SCC be managed?

Answer 124

* Consider a suspected cancer referral pathway (for an appointment within 2 weeks)

Question 125

What are the risk factors for squamous cell carcinoma?

Answer 125

* Excessive exposure to sunlight / psoralen UVA therapy * Actinic keratoses and Bowen's disease * Immunosuppression e.g. following renal transplant, HIV * Smoking * Long standing leg ulcers (Marjolin's ulcer) * Genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism

Question 126

How are SCC treated?

Answer 126

* Surgical excision with 4mm margins if the lesion <20mm in diameter, if >20mm then margins should be 6mm * Mohs micrographic surgery may be used in high risk patients and in cosmetically important sites

Question 127

Which factors indicate good prognosis of SCC?

Answer 127

* Well differentiated tumours * <20mm diameter * <2mm deep * No associated diseases

Question 128

Which factors indicate poor prognosis of SCC?

Answer 128

* Poorly differentiated tumours * >20mm in diameter * >4mm deep * Immunosuppression for whatever reason

Question 129

What is Bowen's disease?

Answer 129

* Type of intra-epidermal SCC * More common in elderly females * 3% chance of developing invasive skin cancer

Question 130

What are the clinical features of Bowen's disease?

Answer 130

* Red, scaly patches | * Often occur on sun exposed areas such as the lower limbs

Question 131

What are the management options for Bowen's disease?

Answer 131

* Topical 5 fluorouracil or imiquimod * Cryotherapy * Excision

Question 132

What is a melanoma?

Answer 132

* Also known as a malignant melanoma is a subtype of skin cancer caused by the abnormal proliferation of melanocytes which are pigment containing cells * Melanoma is described as in situ if confined to the epidermis, invasive if spread to the dermis and metastatic if spread to other tissues from the skin

Question 133

What are the four common subtypes of melanoma?

Answer 133

* Superficial spreading melanoma * Nodular melanoma * Lentigo maligna melanoma * Acral lentiginous melanoma

Question 134

Which subtypes of melanoma are the most common?

Answer 134

* Superficial spreading, nodular and lentigo maligna make up 90% of all diagnosed malignant melanomas * Acral lentiginous melanoma make up 10%

Question 135

What are the features of a superficial spreading melanoma?

Answer 135

* Most common type * Often stays within the epidermis for long periods and usually spreads horizontally and thus referred to as having a “radial growth phase” * Superficial spreading melanoma may present as a flat pigmented lesion with asymmetrical or irregular borders * Usually identified in the fourth to fifth decades and most commonly found on sun-exposed sites

Question 136

What are the features of a nodular melanoma?

Answer 136

* Second most common type * Often presents as an atypical nodule that may ulcerate and bleed easily * It may be difficult to diagnose as it can present as a darkly pigmented lesion or red/pink in colour (amelanotic) and lacks ABCDE features * Usually presents from the fifth or sixth decade and commonly occurs on the legs or trunk. * Nodular melanoma has a vertical growth pattern and thus can spread rapidly in comparison to other forms of melanoma

Question 137

What are the features of a lentigo maligna (melanoma)?

Answer 137

* Also known as Hutchinson’s melanotic freckle and is a precursor to lentigo maligna melanoma * Presents as a slow growing patch of brown skin, often resembling a freckle in its early stages * Cancerous cells of lentigo maligna are described as 'in-situ', meaning they are present in the epidermis and not yet invading deeper tissue * Lesions usually grow slowly over several years most common in older people on sun-exposed skin, most often found on the head and neck

Question 138

What are the features of a lentigo maligna melanoma?

Answer 138

* Develops from a pre­invasive phase lentigo maligna * It is an irregularly ­shaped brown macule which grows slowly, and over time may develop irregular colours (dark brown, black, blue) * Lentigo maligna melanoma usually grows horizontally initially but can form nodules once it enters the vertical growth phase

Question 139

What are the features of an acral lentiginous melanoma?

Answer 139

* Most common on the soles of the feet but can also occur in the palms of hands and in the nail bed * Presents with a flat pigmented area, slowly increasing in size, becoming increasingly irregular in colour and border * May be covered with reactive callus (corn) if on the sole and eventually may develop a nodule with ulceration and bleeding * May be brown or black discolouration (Hutchinson's sign) in advanced growth. It can occur in all ethnic groups but is most common in darker skin types

Question 140

What are the features of a genital melanoma?

Answer 140

* Most common on the glans penis or vulva and, as for acral lentiginous melanoma, usually starts as a flat brown macule which increases in size over time, becoming more irregularly pigmented and developing a pink nodule over time when in vertical growth

Question 141

What are the features of an amelanotic melanoma?

Answer 141

* Typically presents as a pink coloured or erythematous nodule which may completely lack pigmentation, but a small focus of pigment is usually present, often at the edge. It is usually a variant of nodular melanoma

Question 142

What are the risk factors for developing a melanoma?

Answer 142

* A personal history of skin cancer. * A family history of skin cancer. * Pale skin (Fitzpatrick Skin Type I and II) that burns easily. * Red, blonde or light-coloured hair. * Blue or green eyes. * History of sunburn, particularly blistering sunburn in childhood. * A history of indoor tanning. * A large number of moles. * Unusually high sun exposure - the risk is higher with intermittent sun exposure than regular exposure. * Use of tanning beds or sun beds, particularly if 10 or more sessions. * Increasing age — the incidence of malignant melanoma increases with age in both men and women, from 15 years of age onwards. * Organ transplant recipients (rare)

Question 143

How common is melanoma?

Answer 143

* Melanoma is the 3rd most common skin cancer in the UK * 1/3 in every cancers diagnosed worldwide is skin cancer * Melanoma is the 2nd most common cancer in adults aged between 25 and 49

Question 144

What are the prognostic factors for malignant melanoma?

Answer 144

* Invasion depth of a tumour (Breslow depth) is the single most important factor in determining prognosis of patients with malignant melanoma

Question 145

How does Breslow thickness (of melanoma) relate to 5 year survival?

Answer 145

Approximate 5 year survival * <1 mm = 95-100% * 1-2 mm = 80-96% * 2.1-4 mm = 60-75% * >4 mm = 50%

Question 146

What are the differential diagnoses for melanoma?

Answer 146

* Angiomas and haemangiomas * Angiokeratomas * Pyogenic granulomas * Kaposi's sarcoma

Question 147

How should assessment of a malignant melanoma be done?

Answer 147

* History, assess for: - Pigmented lesions which stand out from the crowd because they are different (Ugly Duckling sign) - Dermatoscope can be used to examine skin lesions and may more accurately distinguish between benign and malignant lesions * Use the weighted 7 point check list for assessment of pigmented skin lesions and to determine referral * Major features of the lesion (2 points each): - Change in size - Irregular shape or border * Minor features of the lesion (1 point each) - Largest diameter 7 mm or more - Inflammation - Oozing or crusting of the lesion - Change in sensation (including itch) * Suspicion is greater for lesions scoring 3 points or more * If strong concerns about cancer, any one feature is adequate to prompt urgent referral under the 2 week wait rule * Inspect the rest of the skin for suspicious pigmented lesions or dysplastic naevi * Palpate major lymph nodes in the regional drainage area if the lesion is suspicious of melanoma

Question 148

When should biopsy of melanoma be considered?

Answer 148

* Do not biopsy in primary care - If a lesion is suspected to be a melanoma, urgently refer (2 week wait) to a dermatologist, plastic surgeon or other suitable specialist with experience of diagnosing melanoma and ensure the person is promptly followed up

Question 149

What should be included in the referral for a suspected malignant melanoma?

Answer 149

* Location * Size * Shape * Colour * How long the lesion has been present * Changes * Symptoms (inflammation, oozing, crusting, bleeding, change in sensation) * Palpable lymph nodes * Risk factors for melanoma

Question 150

What is the ABCDE assessment of skin lesions recommended by the British Association of Dermatologists?

Answer 150

* Asymmetry - the two halves of the area may differ in shape. * Border - the edges of the area may be irregular or blurred, and sometimes show notches. * Colour - this may be uneven. Different shades of black, brown and pink may be seen. * Diameter - most melanomas are at least 6mm in diameter. Report any change in size, shape or diameter to your doctor. * Expert - if in doubt, check it out! If your GP is concerned about your skin, make sure you see a Consultant Dermatologist, the most expert person to diagnose a skin cancer

Question 151

How should excision be performed in relation to Breslow thickness of malignant melanoma?

Answer 151

* Lesions 0-1mm thick - 1cm * Lesions 1-2mm thick - 1-2cm * Lesions 2-4mm thick - 2-3cm * Lesions >4mm thick - 3cm Further treatments such as sentinel lymph node mapping, isolated limb perfusion and block dissection of regional lymph node groups should be selectively applied

Question 152

What are the different types of leg ulcers?

Answer 152

* Venous leg ulcers * Marjolin's ulcer * Arterial ulcer * Neuropathic ulcer * Pyoderma gangrenosum

Question 153

What are the clinical features of a venous ulcer?

Answer 153

* Mostly due to venous hypertension, secondary to chronic venous insufficiency (other causes include calf pump dysfunction or neuromuscular disorders) * Ulcers form due to capillary fibrin cuff or leucocyte sequestration * Features of venous insufficiency include oedema, brown pigmentation, lipodermatosclerosis, eczema * Location above the ankle, painless * Deep venous insufficiency is related to previous DVT and superficial venous insufficiency is associated with varicose veins * Doppler USS looks for presence of reflux and duplex USS looks at the anatomy/flow of the vein * Management: 4 layer compression banding after exclusion of arterial disease or surgery * If fail to heal after 12 weeks or >10cm2 skin grafting may be needed

Question 154

What are the clinical features of a Marjolin's ulcer?

Answer 154

* Type of squamous cell carcinoma * Occurring at sites of chronic inflammation e.g. burns, oesteomyelitis after 10-20 years * Mainly occur on the lower limb

Question 155

What are the clinical features of an arterial ulcer?

Answer 155

* Occur on the toes and heel * Painful * May be areas of gangrene * Cold with no palpable pulses * Low ABPI

Question 156

What are the clinical features of neuropathic ulcers?

Answer 156

* Commonly over plantar surface of metatarsal head and plantar surface of the hallux * Plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients * Due to pressure * Management includes cushioned shoes to reduce callous formation

Question 157

What are the clinical features of pyoderma gangrenosum?

Answer 157

* Associated with IBD/RA * Can occur at stoma sites * Erythematous nodules or pustules which ulcerate